Analysis Flooding and Capsizing The structural modifications made to the workboat in 2002 decreased its inherent transverse stability characteristics (see Photo6 and Photo7). In a lightship condition, the freeboard at the aft end in way of the drain hole was minimal and the workboat had an initial trim by the stern. The trim was further increased by the loaded condition of the boat at the time of the occurrence. In this condition, the drain hole on the port side was submerged. When the vessel went astern, the motor well flooded rapidly and submerged the lower part of the transom. Water then flowed onto the main deck forward of the superstructure via the drain pipes, accumulating on the deck until the sill height was reached, and flooded the lower storage compartment. The non-watertight conduit opening in that compartment permitted water to downflood into the centre compartment beneath the main deck. The bilge pump in the centre compartment was fitted with a manual switch only and the operator had no way of knowing the amount of water in the compartment. The vessel's trim by the stern was increased and the waterplane area was reduced until the vessel lost all positive stability and capsized due to the cumulative effect of: weights of persons and equipment added above the main deck and towards the aft end of the workboat, and the weight and the free surface effects of liquids including the water on deck and flooded compartment. Lifesaving Equipment Considering the size of the vessel, the PFDs were stowed in the upper storage compartment, in a location readily accessible to passengers and crew. However, the sudden capsizing precluded access to the PFDs. As demonstrated in this occurrence, emergency situations for small vessels develop rapidly. Good seamanship practices suggest that consideration be given to wearing personal lifesaving equipment during transit, especially during inclement weather. Cold Water Immersion The greatest effects of cold water immersion occur below 15C. Often, the first shock of exposure to cold water causes heart palpitations and takes the breath away. Within a few minutes, the hands will not be able to grasp or hang onto anything. Water at 4C, as in this occurrence, makes swimming even more difficult or near impossible because breathing and muscles are severely affected. After the capsizing, the distance to shore was a few metres. However, as a result of the low water temperature, the crew member, who was reported to be in good health and to be a good swimmer, experienced cold shock and lost the ability to stay afloat unaided, or swim to shore. Alerting Authorities in Emergency The only means of communication on board was by cellular telephone. After the cellular telephone became submerged, it became inoperative. Although it was off-season, the survivors were able to find a serviceable telephone. The vessel was neither equipped with VHF nor an EPIRB, nor were they required. In the absence of an effective means of communication to alert authorities in an emergency or distress situations, valuable time is lost in initiating rescue effort. Timely response of SAR is critical. Safety Awareness The owner, aware of the danger of hypothermia and drowning during cold climatic conditions, purchased floater suits for his workers. However, an informal safety approach permitted unsafe practices to go undetected, as demonstrated by this occurrence. Despite the forecast of cold temperatures and inclement weather, the floater suits were not carried by the crew. Additionally, the risks associated with operating the vessel in inclement weather were not fully appreciated; this fact is depicted in neither the crew nor the passengers donning personal lifesaving equipment. Small Commercial Vessel Safety Under the previous licensing regime, there was no distinction made between licences issued to commercial vessels and pleasure craft. As such, commercial vessels could not be readily identified. Under the new regime, commercial vessels are licensed separately. There are an estimated 50000SCVs operating in Canada.12 As of May2007, TC has indicated that 31053SCVs were registered, and that 9020 were licensed. Small vessels such as the workboat, having a gross tonnage of less than5 and carrying less than 12passengers, are not required to be periodically inspected by TC. The regulatory regime uses the principle of a self-enforcement mechanism as a means to ensure compliance. TC, as a regulator, does not have a regime in place to ensure that the self-enforcement mechanism meets its intended objective. Owners engaged in commercial activity are not necessarily knowledgeable of the marine sector operational requirements. Consequently, an effective compliance monitoring regime ought to include the following elements: Identification of Vessels at Risk: Given the large number of small vessels engaged in commercial activity, they should be readily identifiable for - a targeted approach using a risk profile, and - dissemination of safety information. Ease of Understanding: The regulations ought to be presented in a manner that is readily understood by those to whom they apply. In this instance, the vessel was not licensed as a SCV, did not undergo first inspection and was not inspected subsequent to the major modification. Additionally, the owner had little to no information regarding the regulatory regime and preliminary communications between TC and the owner regarding SVMIP requirements and other safety issues were ineffective. Furthermore, the postponed/poorly attended meetings to give to the stakeholders and agencies the opportunity to discuss regulations and safety issues indicate that communication between TC and the local industry was less than adequate. TC has initiated some measures to further safety of SCVs including the publication of a Small Commercial Vessel Safety Guide (TP14070E), which provides safety-related information for the operation of SCVs.13 In addition to the guide being available through its regional offices, it is forwarded to new owners along with the SCV licence. Identification of vessels is an essential element and primary to the application of a monitoring regime. There are some 10000vessels still to be identified. Until such time as the identification process has been completed, some SCVs will continue to be at increased risk. It is recognized that the use of partnering arrangements is one of the means to further safety, especially in areas of multiple jurisdictions and/or SCV operations. Additionally, provincial governments have a responsibility to ensure that construction site activities are safe, including the use of SCVs. In Quebec, since 1998, a partnering arrangement with TC has been used effectively by linking the province's business licensing system with vessel safety inspection requirements and an additional provincial requirement for vessel insurance. In doing so, SCV activities have been afforded a minimum level of safety. The increased centre of gravity of the modified vessel, when combined with free surface effects of liquids, increased the probability of the vessel losing transverse stability and capsizing. The workboat capsized when the combined weight of the persons in the wheelhouse (which further raised the centre of gravity) and equipment on board allowed water to be shipped on board through the drain holes and over the transom. The bilge pump was not provided with a float-activated switch, nor was there a means for the operator to determine the amount of water accumulated in below-deck compartments. The owner of the small commercial vessel did not contact Transport Canada (TC) for a post-modification inspection, nor was he aware of the need to do so. Despite inclement weather, the personal flotation devices aboard were not worn and the available floater suits were not carried.Findings as to Causes and Contributing Factors The increased centre of gravity of the modified vessel, when combined with free surface effects of liquids, increased the probability of the vessel losing transverse stability and capsizing. The workboat capsized when the combined weight of the persons in the wheelhouse (which further raised the centre of gravity) and equipment on board allowed water to be shipped on board through the drain holes and over the transom. The bilge pump was not provided with a float-activated switch, nor was there a means for the operator to determine the amount of water accumulated in below-deck compartments. The owner of the small commercial vessel did not contact Transport Canada (TC) for a post-modification inspection, nor was he aware of the need to do so. Despite inclement weather, the personal flotation devices aboard were not worn and the available floater suits were not carried. The absence of thermal protection drastically reduces the chances of survival of persons who are in cold water, irrespective of their health condition. The absence of an effective means of communicating distress hampers timely rescue response, jeopardizing lives of passengers and crew. Ineffective communication between TC and the local industry may result in small vessel owners being unaware of important safety and regulatory measures. TC had not identified the workboat as a small commercial vessel. The past system of licensing vessels was not conducive to readily identifying vessels engaged in a commercial operation.Findings as to Risk The absence of thermal protection drastically reduces the chances of survival of persons who are in cold water, irrespective of their health condition. The absence of an effective means of communicating distress hampers timely rescue response, jeopardizing lives of passengers and crew. Ineffective communication between TC and the local industry may result in small vessel owners being unaware of important safety and regulatory measures. TC had not identified the workboat as a small commercial vessel. The past system of licensing vessels was not conducive to readily identifying vessels engaged in a commercial operation. Safety Action Taken Transport Canada On 22 December 2004, the TSB issued Marine Safety Information (MSI)10/04 to Transport Canada (TC) relating to the vessel description, the result of the simulated loading condition and the lifesaving equipment that was recovered from the vessel. The TSB also pointed out that it was unknown how many such vessels were in service, nor how many had been modified after purchase. TC continues to be proactive in looking for contraventions of the Canada Shipping Act. TC is not aware of any similar "modified" vessels; however, several similar "production" hulls do exist. TC inspected the owner's remaining eight vessels; two of these vessels were detained. Following repairs, the vessels were re-inspected by TC. Owner/Operator Subsequent to the accident, the operating company has taken the following safety action: purchased very high frequency (VHF) radios for all the vessels in the fleet and 14employees were trained and certified in VHF radio communication with digital selective calling (DSC); provided Marine Emergency Duties (MED) A3training to 23employees and subcontractors; provided a Small Commercial Vessel Operator Proficiency Course and 11employee were certified; employees and subcontractors were certified in basic first-aid training and in advanced first aid; 3 employees were certified in the transportation of dangerous goods; 18 employees obtained their Pleasure Craft Operator card; and established a formal health and safety committee that has developed safety policies and procedures, including requirements to wear floater suits, filing a sail plan, and pre-departure checks of communication equipment. Safety Concern Of an estimated 50 000 small commercial vessels operating in Canada, TC advises that 31053 are registered and 9020 are licensed as of May2007. There are, therefore, some 10000 yet to be identified. Although TC has initiated measures to further the safety of these vessels, the Board is concerned that, until all small commercial vessels are properly identified, safety information is disseminated, and owners/operators have an understanding of the applicable regulations, these vessels and their crews will continue to be at risk.